MEDICARE: TANESHA MICHELLE UPTON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA20536	FL

General Provider Information

NPI Number	:	1023176955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANESHA MICHELLE UPTON PTA

Provider Business Mailing Address
First Line	:	2519 S US HIGHWAY 1
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5922
Country	:	US
Telephone Number	:	772-460-8386
Fax Number	:

Provider Business Practice Location Address
First Line	:	2519 S US HIGHWAY 1
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5922
Country	:	US
Telephone Number	:	772-460-8386
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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